Retractor

ABSTRACT

A retractor ( 101 ) for retracting the margins of a wound opening ( 103 ) comprises an inner anchoring O-ring ( 105 ) attached to a cylindrical sleeve ( 106 ) at a distal end and a reinforcing O-ring ( 109 ) attached to a proximal end of the sleeve ( 106 ). The sleeve ( 106 ) is led between an inner ring part ( 110 ) and a corresponding recess ( 116 ) in an outer ring part ( 111 ). The outer ring part ( 111 ) has anchor formations ( 120 ) over which the proximal end of the sleeve ( 106 ) is attached to anchor the sleeve ( 106 ). To retract the wound opening ( 103 ) the sleeve ( 106 ) is pulled while the guide rings ( 110, 111 ) are moved against the tissue surrounding the wound opening ( 103 ). This pulls the inner O-ring ( 105 ) against the inside of the tissue adjacent the wound opening ( 103 ), and retracts the wound opening ( 103 ). The sleeve ( 106 ) is manipulated locally for maximum retraction efficiency.

[0001] The invention relates to a retractor. In particular the inventionrelates to a retractor for retracting the margins of an incision or anatural bodily orifice to provide maximum exposure of an organ or bodystructures for examination and/or access for surgical procedures, whilealso providing protection for the exposed sides of the incised tissue.

[0002] Various retractors are known. However in general known retractorsare difficult and cumbersome to use, and/or are relatively expensive. Inaddition known retractors are limited to use with a particular size ofincision and a particular patient anatomy.

[0003] This invention is directed towards providing an improved woundretractor which will overcome at least some of these problems, and inaddition provide a means of wound protection during a surgicalprocedure.

STATEMENTS OF INVENTION

[0004] According to the invention there is provided a surgical woundretractor comprising:—

[0005] a distal anchoring member for insertion into a wound opening;

[0006] a connecting means having an inner wound engaging portion and anouter portion, the wound engaging portion being mounted to the distalanchoring member, the connecting means having an insertion configurationin which the inner wound engaging portion has a reduced radial dimensionand a retracting configuration;

[0007] an external guide means for the outer portion of the connectingmeans;

[0008] the external guide means being movable relative to the connectingmeans to shorten the axial extent of the connecting means and therebybias the wound engaging portion of the connecting member into theretracting configuration to retract the wound opening laterally; and

[0009] external anchoring means for anchoring the connecting means tomaintain retraction of the opening.

[0010] In one preferred embodiment of the invention at least the innerwound engaging portion of the connecting means comprises a sleeve forextending around the wound opening to protect the opening.

[0011] In one embodiment the outer portion of the connecting meanscomprises a sleeve extension of the inner wound engaging portion of theconnecting means. Preferably the connecting means comprises a generallycylindrical sleeve. In a preferred embodiment the guide means comprisesan annular ring means. The annular ring means preferably comprises innerand outer ring parts between which the connecting means is led. In apreferred embodiment the outer ring part includes the anchor means foranchoring the connecting means. In one arrangement the anchor meanscomprises anchor formations on the outer ring to which the connectingmeans is attached on retraction of the opening.

[0012] Preferably the inner ring means defines a projection for locationin a complementary recess of the outer ring with the connecting meanslocated therebetween.

[0013] In one embodiment the inner ring is a relatively loose fit in therecess of the outer ring part.

[0014] Preferably at least portion of one of the ring parts is movablefrom a rest position in which the connecting member is substantiallyclamped between the ring parts to a release position in which at leastportion of the connecting member is movable relative to the ring parts.Ideally only portion of the connecting member is movable relative to thering parts in the release position.

[0015] In another embodiment the inner ring is a relatively tight fit inthe outer ring part to grip the connecting member therebetween.

[0016] In one aspect of the invention the outer ring part comprises aplurality of interconnected segments which are independently movable tofacilitate localised release of the connecting member for adjusting ofthe retraction force applied at the opening. The ring part or segmentthereof is preferably manually manipulable between the clamped restposition and the release position.

[0017] In one embodiment of the invention the connecting means includesa proximal reinforcing means for engagement with the external anchoringmeans. Ideally the proximal reinforcing means is a proximal ring.

[0018] Preferably the distal anchoring means is of resilient material.Typically the distal anchoring means is an O-ring.

[0019] Preferably at least an outer surface of the guide means whichengages with the connecting means is of a material with a lowcoefficient of friction such as polytetrafluroethylene.

[0020] In a particularly preferred embodiment the retractor includes aplatform for attachment of another device to the retractor.

[0021] In an especially preferred arrangement one of the ring partsdefines a platform for attachment of another device to the retractor.

[0022] In another aspect the invention provides a method for retractinga wound opening using a surgical wound retractor comprising a distalanchoring member, a connecting means having a wound engaging portionmounted to the distal anchoring member and an outer portion, an eternalguide means for the outer portion of the connecting means and anexternal anchoring means; the method comprising the steps:—

[0023] positioning the distal anchoring member to be retained inside awound opening with the connecting means extending outwardly therefromthrough the opening;

[0024] moving the external guide means relative to the outer portion ofthe connecting means-to shorten the axial extent of the connecting meansand thereby bias the wound engaging portion into a retractingconfiguration to retract the wound opening; and

[0025] anchoring the connecting means to maintain retraction of thewound opening.

[0026] Preferably the method includes the steps of moving the externalguide means relative to the outer portion of the connecting means topartially retract the wound opening, gripping the outer portion of theconnecting means and pulling it relative to the guide means to fullyretract the wound opening.

[0027] In one embodiment the method includes the steps of:—

[0028] (a) gripping a local section of the outer portion of theconnecting means while the remaining section of the outer portion of theconnecting means is anchored,

[0029] (b) pulling the local section to increase the retraction at alocal area of the wound opening, and

[0030] (c) anchoring the local section of the connecting means.

[0031] Ideally the method includes repeating steps (a) to (c) for otherlocal sections of the outer portion of the connecting means.

BRIEF DESCRIPTION OF THE DRAWINGS

[0032] The invention will be more clearly understood from the followingdescription thereof given by way of example only with reference to theaccompanying drawings, in which:—

[0033]FIG. 1 is an exploded view of a wound retractor according to theinvention;

[0034]FIG. 2 is a perspective view of the retractor of FIG. 1 assembled;

[0035]FIG. 3 is a side cross sectional view of the assembled retractorof FIG. 2;

[0036]FIG. 4 is a perspective view of an unretracted wound opening;

[0037]FIG. 5 is a perspective view illustrating insertion of part of theretractor of FIG. 2 into the wound opening;

[0038]FIG. 6 is a side cross sectional view of the retractor of FIG. 2after insertion;

[0039]FIG. 7 is a plan view of the retractor of FIG. 2 after insertion;

[0040] FIGS. 8(a) and 8(b) are side cross sectional views illustratinglateral retraction of the wound opening using the retractor of FIG. 2;

[0041]FIG. 9 is a side cross sectional view of the retractor of FIG. 2after lateral retraction of the wound opening;

[0042]FIG. 10 is a plan view of the retractor of FIG. 2 after lateralretraction of the wound opening;

[0043]FIG. 11 is a plan view of a part of a guide means of the retractorof FIG. 2;

[0044]FIG. 12 is a side view of the part of FIG. 11;

[0045]FIG. 13 is a cross sectional view along the line A-A in FIG. 11;

[0046]FIG. 14 is a cross sectional view of part of another woundretractor according to the invention;

[0047]FIG. 15 is a cross sectional view of the retractor of FIG. 14, inuse;

[0048]FIG. 16 is an exploded view of parts of another wound retractoraccording to the invention;

[0049]FIG. 17 is a perspective view of the wound retractor of FIG. 16assembled;

[0050]FIGS. 18 and 19 are perspective cut-away views of the retractor ofFIG. 17 in different positions;

[0051]FIG. 20 is a schematic plan view illustrating manipulation of apart of the retractor of FIGS. 17 to 19;

[0052]FIG. 21 is a side cross sectional view of the retractor part inthe configuration of FIG. 20;

[0053]FIG. 22 is a schematic plan view of the retractor part in arelease position;

[0054]FIG. 23 is a side cross sectional view of the retractor part inthe configuration of FIG. 22;

[0055]FIG. 24 is a perspective view of a hand access device for use witha wound retractor according to the invention;

[0056]FIG. 25 is a side cross sectional view of the retractor of FIG. 2with the hand access device of FIG. 24 in position;

[0057]FIG. 26 is a perspective view of a drape for use with a woundretractor according to the invention;

[0058]FIG. 27 is a side cross sectional view of the retractor of FIG. 2with the drape of FIG. 26 in position;

[0059]FIG. 28(a) is a perspective view of a form retaining device in apliable state for use with a wound retractor according to the invention;

[0060]FIG. 28(b) is a perspective view of the form retaining device ofFIG. 28(a) in a stiff state;

[0061]FIG. 29 is a side cross sectional view of the retractor of FIG. 2with the stiffened form retaining device of FIG. 28(b) in position;

[0062]FIG. 30 is an exploded view of the form retaining device of FIG.28 and a clamp;

[0063]FIG. 31 is a side view of the form retaining device of FIG. 28 andthe clamp of FIG. 31; and

[0064]FIG. 32 is a side cross sectional view of the retractor of FIG. 2with the form retaining device of FIG. 28 and the clamp of FIG. 30 inposition.

DETAILED DESCRIPTION

[0065] Referring to FIGS. 1 to 13 there is illustrated a wound retractor101 according to the invention, which in the case illustrated is used toretract the margins of a wound such as an abdominal wound opening 103,as illustrated in FIG. 4.

[0066] The reactor 101 comprises a distal anchoring member, in this casein the form of a resilient inner O-ring 105, for insertion into thewound opening 103, and a connecting means, in this case in the form ofan elastomeric sleeve 106 which is substantially cylindrical. The sleeve106 has an inner wound engaging portion and an outer portion, and thewound engaging portion is attached to the inner O-ring 105. The sleevehas an insertion configuration in which the inner wound engaging portionhas a reduced radial dimension and a retracting configuration to retractthe wound opening 103 laterally.

[0067] An external guide means is provided for the outer portion of thesleeve 106, and in this case the guide means comprises an inner ringpart 110 and an outer ring part 111 between which the sleeve 106 is led.The retractor 101 includes external anchoring means for anchoring thesleeve 106 to maintain retraction of the wound opening 103, and in thiscase the anchoring means is provided by a plurality of anchor formations120 on the outer surface of the outer ring part 111 (FIG. 2), theformations 120 extending radially outwardly to define hooks.

[0068] The outer ring part 111 is of the same annular shape as the innerring part 110 but has a larger diameter and a recess 116. The inner ringpart 110 is of a relatively stiff material and mates with the outer ringpart 111 in the recess 116 to slidably retain the sleeve 106therebetween, as illustrated in FIG. 3. In this case the ring parts 110,111 are a relatively loose fit to facilitate movement of the ring parts110, 111 relative to the sleeve 106 to shorten the axial extent of thesleeve 106 and thereby bias the wound engaging portion into theretracting configuration to retract the wound opening 103 laterally.

[0069] The ring parts 110, 111 are of a material with a low coefficientof friction such as Polytetrafluoroethylene (PTFE). PTFE is a tough,non-resilient material of moderate tensile strength and with excellentlubricity.

[0070] The retractor 101 also includes a proximal reinforcing means forengagement with the anchor formations 120, and in this case thereinforcing means is provided by a resilient outer O-ring 109 of amaterial which is flexible relative to the inner O-ring 105. The outerO-ring 109 is attached to the proximal end of the sleeve 106, the rings105, 109 helping to maintain the open shape of the sleeve 106 at itsextremities (FIG. 2).

[0071] In use the inner O-ring 105 and the sleeve 106 are squeezed intothe insertion configuration for insertion of the inner O-ring 105 intothe wound opening 103 (FIG. 5). The inner O-ring 105 is of a polymericmaterial which facilitates scrunching up of the inner O-ring 105 into alow-profile, elongate shape, as illustrated in FIG. 5, to facilitateease of use. On release of the inner O-ring 105, the resilient O-ring105 returns to its normal O-shape overlapping an inner edge of the woundopening 103 to safely anchor the retractor 101 in the wound, asillustrated in FIG. 6. As may be seen from FIGS. 6 and 7, afterinsertion of the inner O-ring 105, the wound opening 103 issubstantially closed and the sleeve 106 is in a wrinkled compressedconfiguration.

[0072] The sleeve 106 is then pulled while pushing the ring parts 110,111 against the tissue surrounding the wound opening 103, as illustratedin FIG. 8(a), to shorten the axial extent of the sleeve 106 and therebybias the wound engaging portion into the retracting configuration toretract laterally the right-hand side (as viewed in FIG. 8(a)) of thewound opening 103. The right-hand side of the outer O-ring 109 is hookedaround the formations 120 to maintain the right-hand side of the woundopening 103 retracted (FIG. 8(b)). The left-hand side of the sleeve 106is then pulled while pushing the ring parts 110, 111 to retractlaterally the left-hand side of the wound opening 103, as illustrated inFIG. 8(b). The left-hand side of the outer O-ring 109 is then hookedaround the formations 120 to maintain the entire wound opening 103 fullyretracted, as illustrated in FIGS. 9 and 10.

[0073] The separate formations 120 and the configuration of the woundretractor 101 generally allow the sleeve 106 to be readily manipulatedlocally as illustrated in FIGS. 8(a) and 8(b) to provide an optimisedretraction force. Thus, the manipulation is not simply limited to asingle vertical axis but can be carried out in several differentdirections by pulling of the sleeve 106, and localised hooking of theouter O-ring 109 to the appropriate formation 120. In this way theretractor can be tailored to a particular application.

[0074] The recess 116 against which the sleeve 106 is slidably retainedby the inner ring part 110 is C-shaped with an extended upper lip 117,as may be seen in FIG. 13. The upper lip 117 maintains the inner ringpart 110 safely within the recess 116 regardless of the pullingdirection or tensile pulling force exerted on the sleeve 106. It ispreferable to pull the sleeve 106 in a non-vertical direction and toperform localised hooking of the outer O-ring 109, and the extendedupper lip 117 encourages non-vertical pulling of the sleeve 106.

[0075] The elastomeric sleeve 106 lines the side of the retracted woundopening 103, as illustrated in FIG. 9, and thus acts both as a means ofwound retraction and wound protection.

[0076] The surgical wound retractor is of simple construction, is easyto use and can be manufactured inexpensively td provide a disposableunit.

[0077] A single wound retractor according to the invention may be usedfor a wide range of incision sizes and to achieve a range of differentlocalised retraction forces which are required to accommodate theincision, the patient anatomy and the surgical procedure to beperformed.

[0078] In the retractor of FIGS. 1 to 10 the sleeve 106 is a relativelytight fit between the outer and inner guide ring parts 110,111. It isalso possible to configure the outer and inner ring parts 110, 111 sothat the inner ring part 110 is a relatively looser fit in the outerpart 111. In this case the guide means comprises an outer ring part orother annular shape within which slides a second component. The secondcomponent is of the same annular shape as the outer ring part but with alesser diameter and has an exterior compartmental recess designed sothat the outer ring part fits loosely around the second component andboth can easily slide relative to each other. The components fit looselytogether so that an elastomeric sleeve can fit in the gap between themand slide therein. Such an arrangement is illustrated in FIGS. 14 and15. On pulling of a local area of the sleeve 106 as indicated in FIG. 15the inner ring part 110 moves to an appropriate side clamping the sleeve106 at that opposite side while allowing local manipulation of thegripped section of sleeve allowing the local retraction force at thegripped side to be optimised prior to anchoring of the sleeve at thatside. This procedure may be repeated at other local regions of thesleeve 106.

[0079] Refer to FIGS. 16 to 23 there is illustrated another woundretractor 150 according to the invention which is similar to the woundretractor 101 described with reference to FIGS. 1 to 13 and like partsare assigned the same reference numerals in FIGS. 16 to 23.

[0080] In this case the guide means comprises the inner ring part 110and an outer PTFE ring part 151 configured so that the outer ring part151 engages the inner ring part 110 at a plurality of discrete pointscircumferentially spaced around the outer ring part 151 to clamp thesleeve 106 between the inner and outer ring parts 110, 151 at eachdiscrete point. The outer ring part 151 comprises a plurality ofinterconnected segments 155 circumferentially spaced around the outerring part 151 which press on the inner ring part 110 to clamp the sleeve106 and are independently movable to facilitate localised release of thesleeve 106 for adjustment of the retraction force. Cut-out T-slots 156are provided between the segments 155 and a main body 158 of the outerring part 151, and handles 160 project radially outwardly of the mainbody 158 of the outer ring part 151 intermediate the segments 155.

[0081] In use, adjacent handles 160 are manually gripped as illustratedin FIG. 20 to apply a release force in the direction of arrows A whichin turn pulls the local segment 155 in the direction of arrow B from arest position clamping the sleeve 106 (FIGS. 20 and 21) to a releaseposition (FIGS. 22 and 23) in which the sleeve 106 is readily pulled andmanipulated locally. By releasing the clamp between the inner ring part110 and the segment 155 the elastomeric sleeve 106 in readily slid fromone position to another. This arrangement is particularly advantageousto facilitate local manipulation of the retraction force.

[0082] In general, the wound retractor 150 according to the invention isemployed by inserting the inner O-ring 105 into a wound opening 103 andpulling the sleeve 106 so that the inner O-ring 105 Lies flat againstthe interior anatomical surface. The inner O-ring 105 anchors theretractor 150 in the wound and prevents the elastomeric sleeve 106 fromslipping out of the wound opening 103. The guide means clamp is thenreleased by squeezing handles 160 and the ring parts 110, 151 are sliddown the elastomeric sleeve 106 until they come into contact with theexterior anatomical surface. Retraction is achieved by pulling thesleeve 106 to shorten the distance between the inner O-ring 105 and thering parts 110, 151 and thereby displace the elastomeric sleeve 106laterally and with it the margins of the wound opening 103. Theelastomeric sleeve 106 is anchored to maintain retraction of the woundopening 103 by releasing the handles 160 of the outer ring part 151 toclamp the sleeve 106.

[0083] The wound refractors according to the invention also provides aplatform on which a wide range of devices may be mounted. In one casethe platform is provided by an inner projection part of the inner ringpart 110 on which a ring part 171 with a complementary recess 172 may beeasily fitted somewhat in the manner of a snap-type engagement. Variousdevices may be provided with such a ring part 171. For example, asillustrated in FIGS. 24 and 25 the device may be a hand access device175 for use in laparoscopic surgery. Alternatively the device may be adrape 180 (FIGS. 26 and 27) or a form retaining device 185 which ismanipulated to the form of, for example, an organ 187 to be held backand from which air is then evacuated along an evacuation line 186 toretain the desired organ holding configuration (FIGS. 28 and 29).

[0084] The platform may alternatively be provided by a clamp 200 asillustrated in FIGS. 30 to 32. The clamp 200 comprises an upper jaw 201,a lower jaw 202, a clip 203 and an arm 204.

[0085] The clamp 200 is assembled by screwing the clip 203 to the baseof the lower jaw 202, sliding the upper jaw 201 over the lower jaw 202to engage the male projecting parts 208 within the corresponding femalerecesses 209 and extending the arm 204 through the open mouth 207between the upper and lower jaws 201, 202. A plurality of teeth 205 areprovided on the arm 204, the teeth 205 being sized to project upwardlythrough a recess 206 in the upper jaw 201 when the arm 204 is within theopen mouth 207. The teeth 205, as shown more clearly in FIG. 31, areshaped such that the arm 204 may be pulled back through the open mouth207 in a ratchet-type arrangement but cannot be pushed forward again. Asuitable material for the clamp components 201, 202, 203, 204 is springsteel.

[0086] Various devices may be attached to the free end of the arm 204,such as the form retaining device 185, as illustrated in FIG. 30. Inuse, the clip 203 is securely fixed to the wound retractor 101 by asnap-fit arrangement with the form retaining device 185 extending intothe wound opening 103, as illustrated in FIG. 31. The form retainingdevice 185 is then ratcheted laterally across the wound opening 103 toretract, for example, an internal organ 220. The ratchet configurationof the clamp 200 and the rigidity of the form retaining device 185ensure that the internal organ 220 is securely maintained in a desiredposition.

[0087] It will be appreciated that any of the embodiments of the woundretractor according to the invention may be used as a platform on whichto mount other devices for use in various surgical procedures. Suchdevices may include: a capping device to cover the incision site ororifice; a hand-access device to allow the surgical procedure to beconverted from an open procedure into a hand-assisted laparoscopicprocedure; an instrument port for the insertion of instruments; a trocarfor use in laparoscopic surgery; an internal organ retractor to assistin the displacement of internal structures from the operative field; oran illuminating means to deliver illumination to an area shaded from thetheatre lights. It will be clear to those skilled in the art that theenhancements are not limited to the brief list mentioned here.

[0088] The wound retractor may be constructed in other annular shapes.For example the distal and proximal rings attached to the elastomericsleeve may be oval or elliptical instead of circular.

[0089] The retractor may be used to retract and protect the margins of anatural bodily orifice such as the anus or vagina, or can be used toretract and protect the edges of a man-made stoma such as is created fortracheostomy or following gastrointestinal surgery.

[0090] The invention is not limited to the embodiments hereinbeforedescribed which may be varied in both construction and detail.

1. A surgical wound retractor comprising:— a distal anchoring member forinsertion into a wound opening; a connecting means having an inner woundengaging portion and an outer portion, the wound engaging portion beingmounted to the distal anchoring member, the connecting means having aninsertion configuration in which the inner wound engaging portion has areduced radial dimension and a retracting configuration; an externalguide means for the outer portion of the connecting means; the externalguide means being movable relative to the connecting means to shortenthe axial extent of the connecting means and thereby bias the woundengaging portion of the connecting member into the retractingconfiguration to retract the wound opening laterally; and externalanchoring means for anchoring the connecting means to maintainretraction of the opening.
 2. A retractor as claimed in claim 1 whereinat least the inner wound engaging portion of the connecting meanscomprises a sleeve for extending around the wound opening to protect theopening.
 3. A retractor as claimed in claim 1 wherein the outer portionof the connecting means comprises a sleeve extension of the inner woundengaging portion of the connecting means.
 4. A retractor as claimed inclaim 1 wherein the connecting means comprises a generally cylindricalsleeve.
 5. A retractor as claimed in claim 1 wherein the guide meanscomprises an annular ring means.
 6. A retractor as claimed in claim 5wherein the annular ring means comprises inner and outer ring partsbetween which the connecting means is led.
 7. A retractor as claimed inclaim 6 wherein the outer ring part includes the anchor means foranchoring the connecting means.
 8. A retractor as claimed in claim 7wherein the anchor means comprises anchor formations on the outer ringto which the connecting means is attached on retraction of the opening.9. A retractor as claimed in claim 6 wherein the inner ring meansdefines a projection for location in a complementary recess of the outerring with the connecting means located therebetween.
 10. A retractor asclaimed in claim 6 wherein the inner ring is a relatively loose fit inthe recess of the outer ring part.
 11. A retractor as claimed in claim 6wherein at least portion of one of the ring parts is movable from a restposition in which the connecting member is substantially clamped betweenthe ring parts to a release position in which at least portion of theconnecting member is movable relative to the ring parts.
 12. A retractoras claimed in claim 11 wherein only portion of the connecting member ismovable relative to the ring parts in the release position.
 13. Aretractor as claimed in claim 6 wherein the inner ring is a relativelytight fit in the outer ring part to grip the connecting membertherebetween.
 14. A retractor as claimed in claim 6 wherein the outerring part comprises a plurality of interconnected segments which areindependently movable to facilitate localised release of the connectingmember for adjusting of the retraction force applied at the opening. 15.A retractor as claimed in claim 14 wherein the ring part or segmentthereof is manually manipulable between the clamped rest position andthe release position.
 16. A retractor as claimed in claim 1 wherein theconnecting means includes a proximal reinforcing means for engagementwith the external anchoring means.
 17. A retractor as claimed in claim16 wherein the proximal reinforcing means is a proximal ring.
 18. Aretractor as claimed in claim 1 wherein the distal anchoring means is ofresilient material.
 19. A retractor as claimed in claim 1 wherein thedistal anchoring means is an O-ring.
 20. A retractor as claimed in claim1 wherein at least an outer surface of the guide means which engageswith the connecting means is of a material with a low coefficient offriction.
 21. A retractor as claimed in claim 20 wherein at least anouter surface of the guide means is of polytetrafluroethylene.
 22. Aretractor as claimed in claim 1 including a platform for attachment ofanother device to the retractor.
 23. A retractor as claimed in claim 6wherein one of the ring parts defines a platform for attachment ofanother device to the retractor.
 24. A method for retracting a woundopening using a surgical wound retractor comprising a distal anchoringmember, a connecting means having a wound engaging portion mounted tothe distal anchoring member and an outer portion, an external guidemeans for the outer portion of the connecting means and an externalanchoring means; the method comprising the steps of:— positioning thedistal anchoring member to be retained inside a wound opening with theconnecting means extending outwardly therefrom through the opening;moving the external guide means relative to the outer portion of theconnecting means to shorten the axial extent of the connecting means andthereby bias the wound engaging portion into a retracting configurationto retract the wound opening; and anchoring the connecting means tomaintain retraction of the wound opening.
 25. A method as claimed inclaim 24 including the steps of moving the external guide means relativeto the outer portion of the connecting means to partially retract thewound opening, gripping the outer portion of the connecting means andpulling it relative to the guide means to fully retract the woundopening.
 26. A method as claimed in claim 25 including the steps of:—(a) gripping a local section of the outer portion of the connectingmeans while the remaining section of the outer portion of the connectingmeans is anchored, (b) pulling the local section to increase theretraction at a local area of the wound opening, and (c) anchoring thelocal section of the connecting means.
 27. A method as claimed in claim26 including repeating steps (a) to (c) for other local sections of theouter portion of the connecting means.